Very few postoperative survivors will consult a doctor “when can they resume sex? ” when they are discharged from the hospital, and few doctors will explain the precautions related to the patient’s postoperative sexual behavior. After all, this is an embarrassing question. Normal sexual function is a biological psychological process, usually has been found to be related to age, depressive symptoms, disease and hormone 21. Some survey results show that sexual dysfunction (SD) after cardiac surgery is widespread 22. SD can be multi-factorial in etiology with hormonal, anatomical, physiological, and psychological effects 9. Previous studies have shown that sexual function changes after organ transplantation: For example, patients with end-stage renal failure undergoing kidney transplantation have been found to get improved sexual function 23-25; however, despite the improvement in total quality of life (QOL) and physical function, SD seems to persist after heart transplantation. Tabler and colleagues found that the causes of SD after transplantation included drug side effects, fear of death during intercourse, depression, body-image concerns, uncertainty about the gender of the donor, and changes in roles and responsibilities in the family 26. There is little information about the quality of sexual life and mood disorders of survivors after AAD surgery.
1. SD Prevalence
Our research shows that there is a certain prevalence of SD after AAD surgery (38.9%), and the prevalence of 47.1% in the elderly is significantly higher than 27.4% in the youth. This may be because the majority of our research subjects are elderly people, most of whom are associated with chronic diseases. With age, the level of androgens in the body decreases. The decline of testosterone can reduce erectile response, sexual satisfaction and sexual frequency and also has a certain effect on ejaculation function 27. In addition, the incidence of chronic diseases such as hypertension, diabetes, and dyslipidemia gradually increases with age, and the total number of combined chronic diseases is related to low interest in sexual activities or decreased satisfaction 28. In view of this, in the cardiac rehabilitation program for patients after AAD surgery, instruct patients to actively treat various chronic diseases and strictly control blood pressure, blood sugar and blood lipid levels may be an effective way of improving the quality of sexual life.
2. SD and QOL
(1) SD is closely related to physical health
Our results show that the AAD postoperative SD patients showed obvious impairment of QOL, and we found that the impaired QOL was mainly manifested in physical health items, associated without depressive symptoms or clinically measurable mental health, which is consistent with the trend of QOL changes after heart transplantation 9. The results of SF-12 show that the total physical health of AAD postoperative SD patients, including general health, physical function, and physical role limitations are lower than those of non-SD patients, but the total mental health items, including social function, emotional limitations and mental health, are not found significant difference between AAD postoperative SD patients and non-SD patients. Although this does not imply a causal relationship, this study suggests that AAD postoperative SD is more strongly related to physical health than mental health and may indicate that the occurrence of SD in this population is more likely to be a physical cause rather than a psychological cause. This is consistent with the results of previous studies: the study of kidney transplant recipients found a link between sexual function and physical health 29. Wolpowitz and Barnard 30 found that after a heart transplant, a quarter of male subjects were unable to obtain or maintain an erection, despite their desire to have sex with their partners. Heart transplant patients found increased libido but impaired erectile function, resulting in a mismatch between libido and performance 31.
(2) SD in the youth group is closely related to mental health
In addition to aging and other confounding factors such as drugs and lifestyle factors, studies have shown that poor mental health is also related to SD. For example, there was a strong relationship between depression and SD 32. Such patients mainly manifested as decreased libido, erectile function and decreased sexual activity 33,34. The relationship between mental health with AAD postoperative SD prevalence needs to be further clarified. Although self-reported depression and anxiety after AAD surgery were common 22, in our study, SD patients were not found a significantly closer relationship with mental health or depressive symptoms than non-SD patients. But interestingly, it was found that the impaired QOL of AAD postoperative SD patients in the youth group is mainly reflected in the mental health items rather than physical health items. The mental health score of the youth group was lower than that of the elderly group, and the depression symptoms scores were higher than that of the elderly group, although the physical health was not impaired as severe as that of the elderly group. These results indicate that although our previous study found that SD was generally more strongly related to psychological than mental factors after AAD surgery, the opposite is true for young SD patients, with more psychological factors than physical factors. Mild aerobic activity has been shown to promote physical and mental health and lower resting blood pressure after AAD surgery 35. Clinicians will encourage postoperative AAD survivors to perform mild to moderate aerobic exercise when discharged from the hospital. Previous investigations have shown that postoperative AAD survivors have significantly reduced physical activity after surgery. Analyzing the reasons of increase in physical inactivity, it was unlikely due to impaired physical function after AAD, because most of our patients showed adequate physical function status, and only 1% of patients needed home care 22. This most likely results from psychological depression or anxiety or fear. Studies have shown that serious health conditions such as ATAAD are often associated with fear and can trigger a post-traumatic stress disorder (PTSD) 36, which is diagnosed more frequently in the case of female and younger patients 37,38. Our research also shows that the physical health of AAD postoperative SD patients in the youth group did not show better than that of the elderly group, instead, the total mental health score is significantly lower than that of the elderly group, and the depression score is significantly higher than that of the elderly group. The questionnaire suggests that young patients think sexual activity is strenuous exercise and are fear of corresponding complications resulting from sexual activity. For example, due to the implantation of the stent, some young patients may worry about the displacement and shedding of the stent during sexual activity, and these psychological burdens will affect the patient's sexual function such as erection and ejaculation to a certain extent and sexual dysfunction aggravate the impairment of mental health in turn. Therefore, when postoperative AAD survivors recovers the physical health, it is unnecessary to deliberately avoid sexual activities 39. Health care providers should evaluate sexual health and encourage patients eliminate this unfounded psychological fear after AAD surgery. In recent years, many previous studies 40-43 have shown that providing sex education and counseling to patients and their spouses can improve the quality of sexual life of patients with cardiovascular disease and patients after cardiac surgery. It can be seen that it is necessary for postoperative AAD survivors to receive sexual health education provided by medical staff during hospitalization or discharge.